D.7 Required Compliance Checklist.docx

D.7 COMPLIANCE CHECKLIST – REQUIRED FOR CONTRACTORS TO COMPLETE

Interested parties must complete all sections of the following document. This checklist is provided to assist interested parties in submitting a compliant quote All sections below must be completed with accurate information. Failure to do so will result in a non-compliant quote. If an item is not applicable, indicate “None” or “N/A.” Do not leave any fields blank.

1. Contractor Information Name of Prime Contractor

DBA - Doing Business As (If applicable)

SAM UEI

Cage Code

Street Address of Prime Contractor

City, State & Zip

Primary POC – Prime Contractor

Phone Number

Email Address

2. SBA Certifications (Social-Economic Statuses) and active expiration date(s) of the PRIME ONLY.

Certification Mark (x) if held

Service Disabled Veteran Owned SB (SDVOSB)

Veteran Owned SB (VOSB)

Economically Disadvantaged Woman Owned SB (EDWOSB)

Woman Owned SB (WOSB)

8(a) Small Business (8(a))

HUBZone (HUB)

Small Disadvantaged Business (SDB)

3. The following are required based on the requirement document or submittals found on section E.1 FAR 52.212-1 ADDENDUM located on page ___ of the RFQ. Each item is required to be submitted ☐ SF 1449, Most updated. Must be signed ☐ SF 30, Amendment(s) must be signed. Each must be acknowledged on Table B.1 of RFQ.

4. I understand that the above lists must be completed and checked off. Furthermore, I acknowledge that this document must be submitted with the quote package. Any items not completed or checked off will render the package non-compliant and exclude it from consideration in the competition for award of the contract for Ambulance service at Columbus VAACC.

Signature: _____________________________________________________________________

Name: _________________________________________________________________________ Dated: _________________________________________________________________________ Title: ___________________________________________________________________________ Company: ______________________________________________________________________